For several years, the Rapporteur to the UN Commission on Human Rights (now the UN Human Rights Council) and human rights groups have criticized the Israeli government and health care system for denying access to Gazans seeking to receive permits for care in hospitals in Israel, the PA and Jordan. Yet the data show that the number of patients receiving permits for referrals to hospitals in Israel – or the PA or Jordan – increased by 45 percent from 4,932 in 2006 to 7,176 in 2007, and continued to increase in the first six months of 2008. These trends occurred despite a decline in entry approval rates, mostly because of security reasons.

The facts are that Israel has provided ever increasing numbers of approvals of permits since the Hamas takeover of Gaza, despite increasing rocket attacks on Israel’s civilian population, including mortar and terror attacks directed at the Erez crossing used by patients.

At the same time, there have been at least 20 incidents where Palestinians used medical missions to attempt terror attacks.

The premise that guides medical ethics is that there should not be even one death from delay, but sometimes the delays were related to problems of availability of beds, and at other times to security concerns. There were cases in which patients’ deaths or complications were attributable to delays. But in other cases, deaths and complications were attributable to efforts to transfer to Israel critically ill or near terminal patients from Gaza whose care was deemed as bothersome or too costly.

The longer-term solution to the problem of delays associated with referrals is to promote medical capacity-building in Gaza’s hospital and health care systems so that patients should not have to travel elsewhere for critical care.

The mandate of the Rapporteur to the UN Commission on Human Rights has so far been restricted to reporting only on violations of human rights to life, safety, and access to health care of members of one national group, Palestinians, but not members of another group, Israelis.The result is a selective concern with the human rights of one that ignores assaults on the human rights of the other.

Background

Since the Six-Day War in 1967, Gazans have been coming to Israel for medical treatment and for training in many Israeli hospitals, including Hadassah in Jerusalem, Ashkelon, Tel Hashomer, Beersheva, and others. With implementation of the Oslo accords in 1994, the Palestinian Authority reduced access for training and referrals for care as it sought to increase reliance on its own health care system, but in recent years, there has been a tendency towards increased patient referrals to Israeli hospitals.1 Even so, for several years, human rights groups – notably Physicians for Human Rights-Israel (PHR-I), the UN Commission on Human Rights (now the UN Human Rights Council), and World Health Organization (WHO) agencies – have criticized the Israeli government and health care system for denying access to Gazans seeking to receive permits for care in hospitals in Israel.2,3

To examine the validity of these criticisms and their context, we tracked trends (January 2006 to June 2008) for approved permits and reported deaths in individual patients. In parallel, we tracked trends during the same period for rocket, missile, and terror attacks targeting the Erez crossing, through which Gazans enter Israel.

Methods

Our data came from WHO, PHR-I, the Israel Defense Forces (IDF) medical liaison office with Gaza in the office of the Coordinator of Government Activities in the Territories (COGAT), and the Israel Security Agency (ISA, formerly the General Security Service – Shabak).

We prepared two parallel timelines. One tracked the number of approved permits, based on data from COGAT and verified by WHO (through December 2007). The other timeline tracked Kassam rocket and other attacks from Gaza directed against Israeli civilian populations, notably in Sderot and Ashkelon, based on sources tracking terror attacks on Israel.4

The Palestinian Authority decides whether Gazan patients receiving approval for medical care in Israeli hospitals are treated there, or in Palestinian hospitals in eastern Jerusalem or the West Bank, or in Jordan. The decision as to where to refer is heavily influenced by the fact that the cost of care is substantially higher in Israeli hospitals and the PA covers these costs.

We also reviewed relevant PHR-I and ISA documents on patients denied access to medical care in Israel and deaths, as well as on terrorists disguised as patients.

Trends in Approvals for Patient Referrals

The data showed that patients receiving permits for referrals to hospitals in Israel – or the PA or Jordan – increased by 45 percent from 4,932 in 2006 to 7,176 in 2007, and continued to increase in the first six months of 2008.5

Although there were fluctuations, the mean rates of permits per month in these three years were 411, 598, and 733 respectively. Table 1 shows that the approval rates among those applying were 90.2 percent in 2006, falling somewhat to 81.5 percent in 2007 and even more sharply to 66 percent in 2008. The substantial increase in approved permits more than offset the increase in percentage of refusals – from 18 to 34 percent. Throughout the entire period, a much smaller number of Gazans received approval for care in Egypt.

According to COGAT spokesman Peter Lerner, no patient is moved from Gaza to the Erez crossing and evacuated to Israel, the PA, or Jordan until Gaza physicians report that he or she has been stabilized. For patients with critical care problems who are suspected security risks, the ISA decides what to do, without necessarily consulting a doctor (see below). According to Professor Rafael Walden, Head of Vascular Surgery at Tel Hashomer Hospital and a senior consultant to PHR-I, the increase in requests for referrals resulted from system-wide breakdowns in the infrastructure of medical care in Gaza (see below). Doctors from PHR-I who visited Gaza in recent months reported severe shortages of basic equipment, replacement parts, broken equipment, and shortages of medications, which they attributed to security and political closures. As terror attacks increased following the Hamas takeover, security concerns were the major reason for the increase in the number of refusals.

Nearly all referrals were for medical conditions other than traumatic injuries, except for June 2008 when there was an abrupt increase in referrals of Palestinians injured in factional fighting between Hamas and Fatah, and again in early August, when more Gazans fled into Israel.

Trends in Rocket Attacks and Other Acts of Terror Against Israeli Civilians

The foregoing trends in increased approvals occurred despite the Hamas takeover, the Second Lebanon War, the kidnapping of IDF soldier Gilad Shalit, and an increase in rocket and mortar fire from Gaza. In the weeks leading up to an informal ceasefire in June 2008, attacks on the border crossings through which patients had to pass could have been another factor explaining much of the recent drop in applications and approvals of permits (see Figure 1).

Since the Israeli disengagement from Gaza in the summer of 2005, Hamas and its allies have fired more than 6,000 rockets and mortars into Israel.6The number of rocket attacks increased from November 2007 onward, targeting Sderot and other civilian areas. Palestinian terrorists fired some 200 mortar shells and Kassam rockets at the Erez crossing between Israel and Gaza, resulting in substantial damage and injuries to personnel.

During this period there were some 30 foiled attempts at terrorist infiltration, including at least 20 incidents where Palestinians used medical missions to attempt terror attacks. In June 2006, a female suicide terrorist was arrested at the Erez crossing while on her way to carry out an attack on an Israeli hospital. In May 2007, two female bombers received permits but were caught after slipping through security checks.7 On May 22, 2008, a truck loaded with 4.5 tons of explosives exploded just before reaching the crossing.

The ISA published reports on 11 individuals, including those just cited, who used permits for medical care or for family visits to patients already in Israel for the purpose of carrying out terror-related activities. At Erez, three patients admitted under questioning that they had purchased referral notes with bogus medical information from doctors in Gaza. According to the ISA, terror organizations were making a special effort to recruit women, including those who are pregnant, who are less likely to be closely examined and whose heavy clothing more readily conceals suspicious objects.8PHR-I forwarded these patients for approval, unaware of their true status.

Reports of Delays and Deaths

In 2008, WHO and PHR-I published a spreadsheet itemizing details on 32 Gazan patients whose deaths were attributed to delays in processing requests for medical care in Israel and refusals of permits during the period October 1, 2007 to March 1, 2008.9 These months were a peak period for rocket and mortar attacks on Israel, many specifically directed at the Erez crossing (a fact not cited in the WHO/PHR-I report). The report is based on interviews of the families of patients who applied for permits during this period and examinations of their medical records.

Ten of the 32 patients did not receive permits for security reasons. Three were denied permits at Rafah, the gateway from Gaza controlled by Egypt. In five cases, the delay was attributed to lack of available vacant beds – a severe problem in Israel’s overburdened health care system. In one case, a patient reported by PHR-I as dead from lack of treatment was found to be alive in Gaza, and in other case, a patient reported as dying from cancer as a result of non-referral was actually treated in Israel and returned home before dying. One male, aged 21, was reported as having stomach cancer, and another was a 68-year-old female with liver cancer, conditions for which referral would do little to alter a dismal prognosis. Four infants under one year old and one child under the age of 5 were among those whose deaths were attributed to delays or non-receipt of permits.

In July 2007, there was an outbreak of violence between Hamas and Fatah leaving 170 dead and hundreds of others injured from gunshot wounds. Following this violence, PHR-I presented evidence of delays in providing access to care and subsequent death of 3 individuals and loss of limbs in 4 others, and published a letter by Professor Rafi Walden, Head of Vascular Surgery at Tel Hashomer, in support of a petition to the Israeli High Court of Justice demanding the opening of the crossings to the sick and wounded, and the provision of entry permits for 26 patients in urgent need of medical care in Israel.10 The Court, distinguishing between danger to life and danger to limb, rejected the petition.

The facts are that Israel has provided ever increasing numbers of approvals of permits since the Hamas takeover of Gaza, despite increasing rocket attacks on Israel’s civilian population, including mortar and terror attacks directed at the Erez crossing used by patients.

Is Israel Meeting Its Obligations to Provide Access to Medical Care for Gazans?

Israel totally withdrew its military and civilian presence from all of Gaza in 2005 and no longer occupies the territory.

The robust upward trend in approvals for referrals occurred despite the sharp rise in Kassam rocket attacks from Gaza and a four-fold increase in the nationwide death toll from terror attacks inside Israel in 2008 (28 in the first six months compared to 13 in all of 2007).11

Has Hamas Met Its Obligations to Respect the Erez Crossing as a Medical Sanctuary Protected from Terror Attacks?

Sadly, the question to be asked is whether Hamas’ repeated attacks on the Erez crossing,which place both providers and patients at risk, are war crimes or crimes against humanityas defined bythe UN Charter.

Have Delays in Approvals for Referrals Resulted in Deaths of Patients?12

The premise that guides medical ethics is that there should not be even one death from delay. The position of PHR-I is that inserting security checks into the medical decision-making process introduces delays which endanger life and limb, and therefore violates the core values of medical ethics. The spokesperson for COGAT has declared that Israeli policy is that everyone from Gaza, including those who are security risks, are entitled to treatment, if not in Israel, then in the PA or Jordan.

Concerning the 32 cases in which deaths occurred allegedly following denial of entry permits, in how many was there a cause-and-effect relationship between delay and loss of life? Clearly, in some cases, loss of life or limb occurred as a result of delays, but sometimes the delays were related to problems of availability of beds, and at other times to security concerns. In others, we have to ask whether referral would have made a difference between survival and death beyond acute palliative relief. Information is not available on how many cases involved efforts to transfer to Israel critically ill or near terminal patients from Gaza whose care was deemed as bothersome or too costly – a practice known to anyone familiar with everyday hospital care everywhere.

Assigning a doctor to be on call to the team at the Erez crossing – a recommendation of PHR-I – is very sensible,13 but this arrangement cannot be expected to eliminate the need for security checks – which were introduced by security authorities following the infiltration attempts of women patients with bombs strapped to their bodies. The longer-term solution to the problem of delays associated with referrals is to promote medical capacity-building in Gaza’s hospital and health care systems so that patients should not have to travel elsewhere for critical care. To achieve this objective, COGAT has made approaches to WHO and to donor countries to fund capacity-building in the Gaza Strip for treatment and training of Palestinian personnel, and to facilitate access of foreign expertise to engage in this capacity-building.14 The definitive solution is for Gazans to stop the terror which necessitates the security checks and condemns them to living in a huge prison of their own making.

Allegations of Coercive Pressures on Patients

PHR-I has charged that the Israel Security Agency was using the threat of not granting approval for medical permits to coerce Gazans into supplying intelligence information to Israel.15 What are the true facts? What are the ethical issues?

There is no question that the use of coercion in a medical setting to extract security information is in conflict with established medical codes of ethics. But are the ethical issues surrounding non-coercive interrogation as simple and straightforward as suggested in a brief on ethics attached to the PHR-I document on delays in care?

We were not in a position to verify or refute these charges, whichare based on information in filmed interviews of Gazans in Gaza. Can we be certain that the statements of those who were filmed were not influenced by threats from Hamas, which has established a regime based on intimidation?

The Ethics of Providing Health Care to Patients and Protecting Providers at the Erez Crossing

The right to life and safety is the most elementary of all human rights. The first responsibility of government is to protect the life and safety of its citizens. “Security” is a short-hand term for protecting the right to life and safety of all individual members of the general population, including those who provide health care. In keeping with these principles, non-coercive interrogation of many patients to obtain security information on those who are dangerous would seem to be an elementary precautionary measure for protecting the right to life and safety, in light of Hamas’ use of patients as suicide terrorists and its terror attacks directed at the Erez patient crossing.

The interrogations, delays, and refusals at checkpoints are a consequence of applying the same precautionary principles that guide questioning, frisking, body checks, and baggage checks at airports, where tens of millions are forced to endure inconveniences and delay to detect and deter danger from a tiny number of terrorists. At the Erez crossing, the risks that there will be a terrorist infiltration are far greater than at airports – by several orders of magnitude.16

It follows that the state authorities have to do everything possible to foil and deter terrorists who have medical permits, given the catastrophic consequences of failure. Equally true, PHR-I and WHO should be fostering initiatives to hold organizations accountable for attacking and sending suicide terrorists through the Erez crossing. Such actions are crimes against humanity. So far, the postures of PHR-I and the regional WHO office have been those of silent bystanders to these attacks.

Medical Care Provided to Palestinians by Israel

Nationwide, Israeli hospitals provide a large amount of medical care to Palestinians. For example, many Palestinian patients are treated at the two Hadassah hospitals in Jerusalem (Mt. Scopus and Ein Kerem), even though the Palestinian Authority does not routinely approve coverage for care at Israeli hospitals. Annually, approximately 123,000 Palestinians are treated at Hadassah, including 15,000 hospitalizations totalling 67,000 hospitalization days annually, as well as 32,000 visits to emergency rooms.17

Since the second Intifada, beginning in September 2000, Hadassah Medical Organization has subsidized care for uninsured Palestinians and has been committing $3 million a year for treatment, reducing fees by over 50 percent for those in need or waiving them altogether. These outlays occurred even though the hospital had to cover the added costs in equipment, supplies and longer hospitalization imposed by mass terror attacks.

Large-scale access to care for Palestinians from the West Bank and Gaza in Israeli hospitals predates complaints of PHR-I and WHO. In addition, Israeli concern for public health and medical care in Gaza predates WHO reports, and indeed goes back to when Gaza was under Israeli military occupation. During this period, infant mortality fell to levels lower than in Egypt, polio was eradicated, and Gazans enjoyed the economic benefits of being linked to the Israeli economy. Medical scientists from Gaza participated in regional research projects in tropical medicine and control of environmental problems.18 WHO was not especially active in these projects, which were funded by the Israeli government, the U.S., the EU, and third-party donors.

Has the UN, Including WHO, Served as an Objective Monitor?

Statements by the UN Commission on Human Rights on access to health care in Israel for Gazans, later repeated by WHO, offer a selective and misleading view of what is happening on the ground. These statements ignore the increase in absolute numbers of approvals. They also ignore the facts concerning terror attacks on the Erez crossing.19

But more fundamentally, the mandate of the Rapporteur to the UN Commission on Human Rights is restricted to reporting only on violations of human rights of members of one national group, Palestinians, but not members of another group, Israelis. The result is a selective concern with the human rights of one that ignores assaults on the human rights of the other. This selective focus is inherently at variance with the core principles of human rights, which are based on respect for the life and dignity of all.

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Notes

* I wish to thank my colleagues Professors Elliot Berry and Ted Tulchinsky of Hebrew University-Hadassah School of Public Health and Community Medicine, Dr. Nili Ramu and Professor Rafi Walden of Physicians for Human Rights-Israel, and Peter Lerner, Spokesperson for the Coordinator of (Israeli) Governmental Activities in the Territories (COGAT) for their comments and critiques. But the responsibility for the information and opinions in this document is mine.

2. Professor John Dugard, formerly Special Rapporteur for Palestinian Occupied Territories of the UN Human Rights Council, published a report to the Fifty-Eighth Session of the United Nations Commission on Human Rights of 18 March 2002 (WHO Geneva website). See also Professor John Dugard, interview in the Bridges issue on Health and Human Rights (Sept.-Oct., 2007) and follow-up rebuttal by T. Tulchinsky, E.D. Richter, and R. Shterkshall, in Bridges -January-February 2008. Professor Richard Falk, his designated successor, has repeated Dugard’s statements. See “Eviscerating Gaza,” Sky News, http://www.playgroundsforpalestine.net/news.php?ID=25

4. Intelligence and Terrorism Information Center, Anti-Israel Terrorism in 2007, and Its Trends in 2008, May 2008.

5. At the time of writing (Aug. 2008), according to the Coordinator of Government Activities in the Territories (COGAT), Palestinian estimates for Jan. 2008 to June 2008 for approved referrals are reportedly some 10 percent less than the figures presented herein. Even with the latter estimates, the upward trend is unchanged.

11. Wm. Robert Johnston, “Chronology of Terrorist Attacks in Israel Part X: 2006-2008,” last updated 3 July 2008, http://www.johnstonsarchive.net/terrorism/terrisrael.html

12. Similar assessments came from Dr. Ambrogio Manenti, former head of the WHO office. See WHO Bridges, Jan.-Feb. 2008.

13. Long waits are common in Israel’s overburdened hospitals. The author’s wife, having fractured her shoulder in October 2007, had to wait 3 hours in the emergency room for x rays, and then another 3 before being seen by house officers on call, despite the fact that the Professor of Surgery and Professor of Orthopedics, both colleagues of the author, tried to expedite matters. Several injured victims of a road accident tied up the entire staff for many hours.

16. Is it possible to carry out a crude risk estimate of the toll, in human lives, of failing to apprehend terrorists exploiting humanitarian permits at the Erez crossing? If the 14 patients receiving permits – out of a total of some 30,000 who applied (Table 1), had not been foiled on their way to their terror bombing missions, we could have expected an average of 8 deaths per each attack, or 112 deaths, based on data on deaths per terror bomb attacks from the past decade. While everything has to be done to prevent deaths in all, delays and refusals associated with interrogation – and their deterrent effect – almost certainly have saved far many more lives than they may have been related to deaths.

19. Dr. John Dugard, the former Rapporteur, when confronted with the information, apologized, but refused to retract these assessments. His assessments ignored the Kassam rocket attacks on civilian populations and incitement by Hamas. Dugard’s repeated falsehoods and misrepresentations raise the question of whether international civil servants should be held to a level of accountability in keeping with professional norms and standards. Professor Dugard, by failing to address Palestinian obligations to respect the human rights of others, Israelis and Palestinians, projects a form of racism, holding the regime in Gaza to a standard lower than expected from responsible actors in the international community.

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Professor Elihu D. Richter is head of the Genocide Prevention Program and Injury Prevention Center, and is the retired head of the occupational and environmental medicine unit, at Hebrew University-Hadassah School of Public Health and Community Medicine in Jerusalem. Since the 1980s, he has been involved in joint projects in epidemiologic research with Palestinian colleagues on asthma, lead, pesticides, dioxins, and endocrine disrupters.

About Dr. Elihu D. Richter

Prof. Elihu D. Richter MD MPH is head of the Genocide Prevention Program and Injury Prevention Center and Director of the Jerusalem Center for Genocide Prevention. He is the retired head of the Unit of Occupational and Environmental Medicine and the Injury Prevention Center at Hebrew University-Hadassah School of Public Health and Community Medicine, and the author of over 150 papers, monographs, and editorials. In recent years he has been working on epidemiologic models for prediction and prevention of genocide, mass atrocities and terror, with specific emphasis on the cause-effect relationship between hate language and incitement and these outcomes.